Today we plan to talk about carcinoma.

The vulva.

We plan to talk on the titles of signs and 

symptoms of carcinoma involving some of the pre cancerous conditions 

leading to carcinoma in the vulva.

Some of the spread patterns of carcinoma,

the vulva.

Next on the treatment of invasive carcinoma,

the vulva and insight to carcinoma,

the vulva and then ending up with 

prognosis of carcinoma.

The vulva and the recurrence.

Carcinoma evolve is not a common G.Y.N

malignancy and ranks after cervix,

uterus and ovary in incidents is 

disturbing at this cancer,

which is the most readily accessible to diagnosis 

since his external in nature,

it's not often diagnosed till late.

In its course.

The cardinal signs of vulvar carcinoma are pure itis 

bleeding and a volver sore 

mass,

which is more often than not overlooked.

Peratis is usually present for prolonged periods up to a year 

before the diagnosis is made.

In a large series involved in large series.

Vulvar masses or Sore was were present for an average of 10 months 

before the clinical or before the histological diagnosis of 

Vulvar cancer was made.

This neglect is both part of the doctor's 

responsibility and part of the patient's responsibility for not 

seeking medical attention sooner.

The average age of the patient with carcinoma and evolve.

A invasive carcinoma is in the 60s 

and secondary to an increasing population of 

elderly people.

More and more evolve.

A carcinoma will be diagnosed in the future.

You can just look at a few slides over here 

In a series of patients,

223 in number.

The presenting symptoms were first peratis with 81 out of 

223 symptoms,

patients complaining of this revolver mass or 

ulcer,

66% of patients or 66 out of 

223 patients.

Volver pain 17 out of 223 

and bleeding another 1700 - 

223.

So again,

the first two most common symptoms are politis 

and a volver mass or an ulcer 

in the age distribution.

If you just disregard this top part,

which is insights or limited invasion 

carcinoma evolve,

which we'll talk about a little later.

This is the invasive group here and you can see the majority of people are in 

their 60s,

year old 

white lesions or Luca play key as they are called,

the vulva have long been associated with vulvar carcinoma.

The common finding of coexistence,

Luca play Kia.

An invasive carcinoma of the Volvo has suggested a cause 

and effect relationship between these two 

lesions,

which in fact does exist but not as common 

as believed by some.

A trophic and hyper characteristic changes.

Have only a small association with vulvar cancer in 

our present And lead to Vulva carcinoma.

And perhaps in less than 10% of cases.

Other predisposing factors like chronic granulomas,

diseases of the vulva such as granuloma,

inguinal granuloma venereal and the young females 

have been stated to cause an increased incidence of carcinoma.

The vulva.

Other associated diseases like diabetes,

obesity,

herpes valve itis and a positive 

V.

D.

R.

L.

Are also associates with carcinoma that 

whatever the predisposing causes and factors for carcinoma.

The Volvo known or unknown routine examination 

and proper biopsy with a high index of 

excuse me.

High index of suspicion is the mainstay in diagnosis 

abnormal looking areas and especially those associated with luke 

should be followed briefly and if they do not regress or respond to 

treatment should be promptly biopsy to aid in 

biopsy areas that are suspicious in blue and 

a dilute solution may be painted on the vulva and 

this may be washed with acetic acid and 

abnormal areas will stay in blue.

This is analogous to staining the 

cervix with schiller's iodine.

Where abnormal areas do not take up stain.

These abnormal areas then should be biopsied and sent for 

histological examination.

Continue treatment with hormone creams steroid creams 

antibiotics with no change in the lesion is to 

be,

is contraindicated and 

is often practiced in many situations leading to the late 

diagnosis of Carvel overcast carcinoma.

We just look at some of the vulvar carcinoma and how they present in the 

clinic at M.

D.

Anderson hospital.

You can see the mons pubis here with a large vulvar 

carcinoma on the labia on the left labia.

Again,

an extensive vulvar carcinoma.

With early changes on the left hand side with 

large fun gating carcinoma on the right hand side,

extending all the way down around the rectum 

again bilateral on both sides.

Another extensive vulva carcinoma on both 

sides of the vulva.

Another very extensive vulva carcinoma involving 

all the vulva,

the vagina and infiltrating into the rectum 

and up the vagina.

This is a vulva carcinoma now between the legs,

which you cannot see that has metastasized to a groin node 

and it's causing ulceration of a groin node.

Will later be talking about the way vulvar carcinoma 

spreads up to the groins and the operations involved in 

taking care of this carcinoma.

Once established as an invasive carcinoma.

Vulvar cancer spreads in orally and predictable fashion 

metastases reached the inguinal nodes in the 

groins via the lymphatic of the mons 

pubis and through the Volvo itself.

Once in the inguinal nodes,

the spread is to the nodes in the 

below the angle nodes are in the femoral triangle,

in the region of the or the region of the 

inguinal ligament and then to the deep nodes in the pelvis.

Only occasionally is this pattern not established 

and different patterns may be established if a mass is in the central 

or a clitoral lesion.

Whether it's extensive lesions,

as we've seen in those some of those slides,

if a melanoma is present or any of the cancer is present on the 

mucosal surfaces of the vagina,

anus or urethra 

in staging.

People with carcinoma,

the vulva.

It's all done by clinical staging and some of the 

staging involves the palpitation of nodes that we 

saw in that last picture in the groin.

It's been shown in a large series of patients for M.

D.

Anderson hospital that bye pal patient 

alone,

you can predict Nodes will be positive 

in a groin by in 70% of 

cases by palpitation alone.

However,

non palpable nodes in the groin Are still 

histological positive at operation.

of 30% of cases Therefore 

complete surgical or movement of all known 

bearing tissues is essential since 30% of them 

will escape your diagnosis by Pal patient.

The operative procedure of choice is a radical valve ectomy 

with removal of the involved lymph nodes involved regional 

lymph nodes.

It's just a slide indicating our 

surgical procedure which is on block removal which is 

just removing everything in one block.

So one stage procedure,

radical valve ectomy,

bilateral mastectomies,

removal of the lymph node tissues,

the mods veneers,

the labor crew folds the perineum above the anus and the high middle 

ring are the borders of the dissection and we'll see some slides of 

this in a minute and this is all 

irrelevant.

This is just a couple of pictures of the operative specimen to show you what is 

removed.

This is a fully catheter going into the urethra 

with the Volvo on either side and the anus is 

still on the patient and down in here.

And this decision is carried just above the anus to 

include up into the groins and you can see all the lymph nodes removed 

from the groins on both sides.

This is on block,

totally done altogether.

Again,

another specimen,

you can see the same thing.

The vulvar carcinoma is right there.

Everything's removed with the lymph nodes in the groins.

one more large vulvar carcinoma on the left here,

everything's removed on block with the groins and 

the lymph node bearing tissues.

Postoperative complications are 

sometimes severe and severe,

not only for medical stand or doctors standpoint,

but also a nursing personnel on the ward.

Most common postoperative complication is that of wound 

breakdown,

which is common for several reasons.

Secondary the large amount of tissue is removed.

As you can see on those slides,

the patients are old.

They have an increased incidence of diabetes and hypertension and 

obesity,

all of which leads to poor tissue healing.

And there's always the contamination of the operative field from the 

normal,

normal floor around the anus and the vagina.

This is just to illustrate some of the postoperative 

features of the of the operation where 

incision has been made and a large mass of tissue has 

been removed in here.

As you saw on the previous slide with the skin pulled together 

under tension and all the lymph nodes in the groins here are removed.

These are just some tape burns up here.

Just another view.

You can see that all the Volvo has been removed now 

and all the note bearing tissue.

This big flap of tissue in here has been removed with the 

vulva 

that doesn't come out through clearly.

But this is a lady a couple of months after radical evolve ectomy 

and you can see the classical y shaped scar.

Let's see what we got.

This is a little better one.

You can see that all the Volvo has been entirely removed.

Now this is the anus down here,

This is the urethra and this is the vagina and all the 

vulva is removed.

This is just one example of a wound breakdown.

You can see it's very extensive.

This is just taken care of locally on the floors by the 

nurses and by the doctors and it cleans up nicely and these are just some small 

little skin grafts placed on here and this patient was entirely healed within two 

weeks of doing this.

One special category which we'll talk briefly about involving 

carcinoma is that of insight to cancer of the 

vulva which is just confined to the very 

superficial layers of cells on the volver surface.

And also another group called Limited invasion where the 

cancer has not penetrated a depth of more than five 

below the skin surface.

The experience at M.

D.

Anderson Hospital has shown that a less than radical procedure may 

be done on these people because the 

incidence of lymphoma task diseases zero so far in the 

series.

The procedure of choice is called a skin involve ectomy where 

just a superficial skin is taken off the vulva and 

then a skin graft is taken from the thigh and placed on the vulva.

This very gives a very satisfactory cosmetic 

appearance rather than 

having the radical procedure as you've seen.

The close follow up is nature is mandatory with these 

patients.

These are the criteria and some of the guidelines for a conservative 

treatment of limited invasion 

carcinoma.

The Volvo.

It is only safe if careful follow up is maintained.

The decision is made with a calculated risk saying that 

you do have a limited invasive cancer but you're willing to 

take out less than a radical procedure and 

hope that these people can have a better cosmetic result and you can 

follow them very adequately.

The patient is made aware that a repeat local resection or 

evolve ectomy may be necessary in the future.

And all the treatment is simple should not 

underestimate the seriousness of the condition.

Just some of the techniques involved again,

this is a Volvo that had a very early insight you 

or limited invasive cancer in it.

It's just the skin has just been taken off it 

area is prepared on the thigh for skin graft.

The skin graft is taken from the thigh 

placed on the Volvo and 

suited in place with a stent just in the vagina 

and you can see that the cosmetic result of this is a lot better than the 

cosmetic result of the previous radical valve ectomy.

Let's talk about some of the results now of treatment for carcinoma.

the treatment or the results and the survivals from 

carcinoma evolve.

Our depended mainly on what nodal 

groups or any of the lymphatic nodes were involved 

with at the time of operation,

how big the lesion was initially.

Uh the overall five year survival taking 

all stages of disease treated for cure 

is 77% of people treated for 

Carson and evolved for cure were alive at five years 

and free of disease.

If the inguinal nodes were positive,

as we saw in some of those pathology specimens,

the the overall survival drops to 40% 

in five years.

If the pelvic nodes are the nodes beyond the 

nodes are positive.

Again,

the survival drops now to 25% 

just indicating that the cancer is spreading further.

With each decrease survival.

If no nodes are positive,

there's 100% of patients that are alive at the end of 

five years or have not died of volver carcinoma at the end of 

five years.

Recurrences are mostly within the first two years of treatment 

with an average of eight months.

And our most common right at the sites of the 

so you can get that back site of the 

Volvo cutaneous margin.

Right in this where the vaginal 

cutaneous margin,

I'm sorry not the Volvo contains the vaginal cutaneous margin most 

recurrences when they arise arise within the first two years,

right around this border where you have put the 

skin to the vagina.

They are treated with either 

radiotherapy or wide local excision 

and the results of treatment are very good 

going the wrong way.

There are some slides on the results of treatment and the results of treatment of 

recurrences.

Okay,

I'm looking at 175 patients treated for cure.

Looking at the year,

this is less than one year survival down to five years 

survival.

And you can see at the end of one year there's 

83.4% alive of 

175 patients treated for cure.

At the end of five years there's still 77.3% 

of people alive and treating all cases of 

carcinoma evolve including all stages.

This is just a slide to demonstrate what we do with 

recurrences.

This is a group of 33 patients who returned to M.

D.

Anderson hospital with recurrent carcinoma evolve after treatment in the 

standard fashion.

As we've outlined,

18 of these patients were treated with a local excision 

and the rest of treatments ranging from radiotherapy to 

chemotherapy to a radical excision.

The important point is that out of these 33 patients that 

present with recurrent carcinoma,

66% are still alive at the end of two years.

In conclusion,

carcinoma evolve.

A is is an often neglected diagnosis with a 

prolonged time between presenting symptoms and 

final histological diagnosis,

High index of suspicion is necessary 

and any visible lesion on the vulva should be biopsied 

promptly with early treatment.

The prognosis is favorable,

and the treatment is usually that of radical surgery,

consisting of radical valve ectomy and encompassing lymph 

nodes.

Close follow up is warranted for even with recurrence,

the prognosis is still favorable.

Thank you.